Abnormal Labor

JI Salas, Shania Myca A

Dystocia
● “Difficult labor”
● Abnormally slow progress
● Abnormalities of:
○ Power
○ Passenger
○ Passage

A. Cephalopelvic Disproportion (CPD)

- Disparity between fetal head size and
maternal pelvis
B. Failure to progress
- Lack of progressive cervical dilation or
halted fetal descent
A. Abnormalities of the Expulsive Forces
● Normal Spontaneous
○ 60mmHg

Types of Uterine Dysfunction

● Hypotonic Uterine Dysfunction
○ Basal tone is normal and uterine contractions have a normal
gradient pattern
○ Pressure during a contraction is insufficient to dilate the cervix
● Hypertonic Uterine Dysfunction/ Incoordinate Uterine
Dysfunction
○ Either basal tone is elevated appreciably or the pressure gradient
is distorted
A. Abnormalities of the Expulsive Forces
Risk Factors for Uterine Dysfunction:
● Neuraxial Analgesia
○ Longer 1st and 2nd stages of labor
● Chorioamnionitis
● Higher station at the onset of labor
● Advanced maternal age
● Maternal Obesity
○ Lengthens 1st stage by 30-60 minutes
A. Abnormalities of the Expulsive Forces
A. Abnormalities of the Expulsive Forces
● Maternal Pushing efforts
○ Heavy sedation of regional analgesia may reduce the
reflex urge to push and may impair the ability to
contract abdominal muscles sufficiently
○ Depending on fetal station and anticipated second
stage, options include emotional support and
encouragement, parenteral analgesia, pudendal
blockade, or neuraxial analgesia
 B. Prematurely Ruptured Membranes
at Term
● Membrane rupture at term without spontaneous uterine
contractions complicates approximately 8 percent of pregnancies.
● Labor stimulation was initiated if contractions did not begin after 6
to 12 hours.
○ Oxytocin is the preferred management
● Hypotonic contractions / advanced cervical dilation
○ Oxytocin is selected to lower potential hyperstimulation risk.
● Unfavorable cervix, no or few contraction, and no significant fetal
heart rate decelerations,
○ Prostaglandin E1 (misoprostol) is chosen to promote cervical
ripening and contractions
● Membranes ruptured >18 hrs
○ Group B streptococcal infection prophylaxis
 C. Precipitous Labor and Delivery
● Extremely rapid labor and delivery
● Causes:
○ Abnormally low resistance of the soft parts of the birth canal
○ Abnormally strong uterine and abdominal contractions, or
○ Rarely from a lack of pain with contractions to cue advanced
labor
● Terminates in expulsion of the fetus in <3 hours.
● Vigorous uterine contractions combined with a long, firm cervix and
a noncompliant birth canal → uterine rupture or extensive
lacerations of the cervix, vagina, vulva, or perineum
○ Amniotic fluid embolism most likely develops
 C. Precipitous Labor and Delivery
● Frequently followed by uterine atony.
● Linked to cocaine abuse and associated with placental abruption,
meconium, postpartum hemorrhage, and low Apgar scores.

● Effects on the neonate:

○ Prevent appropriate uterine blood flow and fetal oxygenation
○ Intracranial Injuries
○ Needed resuscitation may not be immediately available
● Treatment
○ Analgesia is unlikely to modify contractions significantly
○ Magnesium sulfate or terbutaline is unproven
○ A single, intramuscular 250-ug terbutaline dose may be reasonable
in an attempt to resolve a nonreassuring fetal heart rate pattern.
○ Oxytocin administration should be stopped.
 D. Fetopelvic Disproportion
A. Pelvic Capacity
a. Contracted Inlet
● Diagonal Conjugate <11.5cm
● Contributes in the production of abnormal presentations.
○ Face and shoulder presentations are encountered more
frequently and cord prolapses more often.

b. Contracted Midpelvis
● More common than contracted inlet
● Suspected when Interspinous diameter is <10cm.
● Contracted when <8cm.
● Causes transverse arrest of the fetal head
● Obstetrical plane of the midpelvis extends from the inferior margin of
the symphysis pubis through the ischial spines and touches the
sacrum near the junction of the fourth and fifth vertebrae.
 D. Fetopelvic Disproportion
c. Contracted Outlet
● Interischial tuberous diameter 8 cm or less.
● Outlet contraction without concomitant midplane contraction
is rare.

d. Pelvic Fractures
● Fracture pattern, minor malalignment, and retained hardware
are not absolute indications for cesarean delivery.
● Fracture healing requires 8 to 12 weeks and thus recent fracture
merits cesarean delivery.
 D. Fetopelvic Disproportion
● Midpelvis measurements are as follows:
● transverse, or interischial spinous: 10.5 cm;
● anteroposterior, from the lower border o the symphysis pubis to
the junction o S4 and S5, 11.5 cm;
● posterior sagittal, from the midpoint of the interspinous line to the
same point on the sacrum, 5 cm.

● Likely contracted when the sum of the interspinous and posterior sagittal
diameters of the midpelvis—normally, 10.5 plus 5 cm, or 15.5 cm—falls to
</=13.5 cm
 D. Fetopelvic Disproportion
A. Face Presentations
● Neck is hyperextended so that the
occiput is in contact with the fetal
back, and the chin (mentum) is
presenting.

a. Risks:
● Preterm fetuses
● Multifetal gestations
● High Parity
● Fetal Malformation
● Hydramnios
● Anencephaly
 D. Fetopelvic Disproportion
b. Mechanisms of labor:
● With the chin anterior, internal rotation of the
face brings the chin under the symphysis pubis
● Ater anterior rotation and descent, the chin and
mouth appear at the vulva, and the
undersurface of the chin presses against the
symphysis.
● Once the chin clears the symphysis, the neck
can flex.
● The nose, eyes, brow, and occiput then appear
in succession over the anterior margin of the
perineum. After birth of the head, the occiput
sags backward toward the anus.
 D. Fetopelvic Disproportion
C. Management:
● Fetal heart rate monitoring is best done with
external devices to help avoid face or eye
injury.
● Rotation to a mentum anterior position may
occur late in labor. Conversion methods
should not be pursued.
 D. Fetopelvic Disproportion
B. Brow Presentation
● Uncommon and is diagnosed
when that portion of the fetal
head between the orbital ridge
and the anterior fontanel presents
at the pelvic inlet
● Fetal head thus occupies a
position midway between full
flexion (occiput) and full extension
(face).
 D. Fetopelvic Disproportion
B. Brow Presentation
● Commonly unstable and converts
to a face or an occiput
presentation
● Except when the fetal head is
small or the pelvis is unusually
large, engagement of the fetal
head and subsequent delivery
cannot take place as long as the
brow presentation persists
 D. Fetopelvic Disproportion
C. Transverse Lie
● Fetus’ long axis lies approximately perpendicular to
that of the mother.
● Shoulder
○ Usually positioned over the pelvic inlet.
● Head
○ Occupies one iliac fossa, and the breech the
other.
● Shoulder presentation
○ The side of the mother on which the acromion
rests determines the designation of the position
as right or left acromial.
○ The back may be directed anteriorly or
○ posteriorly and also superiorly or inferiorly
 D. Fetopelvic Disproportion
C. Transverse Lie
● Abdomen is unusually wide, whereas the uterine
fundus extends to only slightly above the umbilicus.
● No fetal pole is detected in the fundus, and the
ballottable head is found on one side and the
breech on the other.
● Back is anterior:
○ Hard resistance plane extends across the front
of the abdomen.
○ Posterior, irregular nodules that represent fetal
small parts are elt through the mother’s
abdominal wall.
 D. Fetopelvic Disproportion
C. Transverse Lie
a. Mechanism of Labor
● Spontaneous delivery of a fully developed newborn
is impossible with a persistent transverse lie.
● With a neglected transverse lie, the uterus will
eventually rupture.
● Maternal and fetal morbidity rates with transverse
lie are increased because of the frequent association
with placenta previa, umbilical cord prolapse, and
fetal manipulations during cesarean delivery.
 D. Fetopelvic Disproportion
C. Transverse Lie
a. Mechanism of Labor
● If the fetus is small—usually <800 g—and the pelvis
is large, spontaneous delivery is possible.
● Conduplicato corpore
○ The fetus is compressed with the head forced
against its abdomen.
○ A portion of the thoracic wall below the
shoulder thus becomes the most dependent
part, appearing at the vulva.
○ Head and thorax then pass through the pelvic
cavity at the same time.
 D. Fetopelvic Disproportion
C. Transverse Lie
b. Management
● Active labor in a woman with a transverse lie
typically requires cesarean delivery.
● Dorsoanterior or back down position
○ Neither the fetal feet nor head occupies the
lower uterine segment.
● A low transverse uterine incision may lead to
difficult fetal extraction.
○ Vertical hysterotomy incision is typically
indicated.
● With dorsoposterior or back up position, one or both
feet can be grasped through a low transverse
incision and delivered by breech extraction.
 D. Fetopelvic Disproportion
D. Umbilical Cord Prolapse
● More common with pelvis contraction.
● Most risks stem from an unengaged presenting part and include:
○ Hydramnios
○ Breech presentation
○ Transverse lie
○ Premature or small fetus with weight <2500 g
○ Preterm rupture of membranes,
○ Multifetal gestation

● Funic presentation
○ Umbilical cord is the presenting part.
■ Potent risk factor for prolapse and merits cesarean delivery prior to labor.
 E. Complications with Dystocia
A. Maternal Infection
- Either intrapartum chorioamnionitis or postpartum endomyometritis, is more common
with desultory and prolonged labors.
B. Postpartum Hemorrhage
C. Uterine tears
D. Uterine Rupture
- Abnormal thinning of the lower uterine segment
- the upper segment o the uterus contracts, retracts, and expels the fetus. In response,
the softened lower uterine segment and cervix dilate and thereby form a greatly
expanded, thinned-out tube through which the fetus can pass.
- Pathological Retraction Ring of Bandl
- an abnormal condition that forms when there is an extreme thinning of the
lower uterine segment such as one seen in obstructed labor.
 E. Complications with Dystocia
E. Fistula formation
- Presenting part is firmly wedged into the pelvis.
- Excessive pressure is exerted against tissues lying between the leading part and the
pelvic wall.
- Because of impaired circulation, necrosis may result and become evident several days
after delivery as vesicovaginal vesicocervical, or rectovaginal stulas
F. Lower-extremity nerve injury in the mother
- Can follow prolonged second-stage labor.
- Mainly sensory, and most resolve within 6 months of delivery in most women.

G. Caput succedaneum and molding

Thank you!